Selective neck dissection for hypopharyngeal cancer in the clinically negative neck: should it be bilateral?

The comparison of manual and mechanical anastomosis after total pharyngolaryngoesophagectomy

Background

Total pharyngolaryngoesophagectomy (TPLE) is considered as a curative treatment for hypopharynx cancer and cervical esophageal carcinomas (HPCECs). Traditional pharyngo-gastric anastomosis is usually performed manually, and postoperative complications are common. The aim of this study was to introduce a new technique for mechanical anastomosis and to evaluate perioperative outcomes and prognosis.

Methods

From May 1995 to Nov 2021, a series of 75 consecutive patients who received TPLE for a pathological diagnosis of HPCECs at Sun Yat-sen Memorial Hospital were evaluated. Mechanical anastomosis was performed in 28 cases and manual anastomosis was performed in 47 cases. The data from these patients were retrospectively analyzed.

Results

The mean age was 57.6 years, and 20% of the patients were female. The rate of anastomotic fistula and wound infection in the mechanical group were significantly lower than that in the manual group. The operation time, intraoperative blood loss and postoperative hospital stays were significantly higher in the manual group than that in the mechanical group. The R0 resection rate and the tumor characteristics were not significantly different between groups. There was no significant difference in overall survival and disease-free survival between the two groups.

Conclusion

The mechanical anastomosis technology adopted by this study was shown to be a safer and more effective procedure with similar survival comparable to that of manual anastomosis for the HPCECs patients.

A nomogram for predicting occult lymph node metastasis in early hypopharyngeal cancer with cN0

PURPOSE

To explore the risk factors of cervical occult lymph node metastasis (OLNM) in early cN0 hypopharyngeal squamous cell carcinoma (HPSCC), and construct a nomogram model to predict the risk of OLNM in patients with early cN0 HPSCC.

METHODS

78 cases of early (T₁-T₂) HPSCC patients who underwent hypopharyngectomy were retrospectively analyzed. Univariate and multivariate logistic regression analyses were used to determine independent risk factors and a nomogram was constructed according to the results of the multivariate logistic regression analysis. Model performance was assessed by constructing a receiver operating characteristic (ROC) curve, and discriminatory capacity assessed using the area under the curve (AUC). Calibration was completed using a plotted calibration curve accompanied by the Hosmer-Lemeshow test.

RESULTS

Multivariate logistic regression analysis revealed that age (OR 0.928, 95% CI 0.863-0.997), history of drinking (OR 6.668, 95% CI 1.724-25.788), histological differentiation of tumor (OR 7.269, 95% CI 1.000-52.820), depth of invasion (OR 5.046, 95% CI 1.281-19.874) were independent risk factors of OLNM in early cN0 HPSCC. The ROC curve had an AUC of 0.811 (95% CI 0.713-0.909), which implies good discriminate capacity. The calibration curve and the Hosmer-Lemeshow test (P = 0.972) demonstrated good model fitted and high calibration.

CONCLUSION

A nomogram model based on age, drinking history, histological differentiation of tumor, and depth of tumor invasion was successfully developed to predict occult cervical lymph node metastasis in patients with early cN0 hypopharyngeal cancer.

The survival rate and larynx preservation in elderly cancer patients who received surgical operation: A retrospective cohort study

BACKGROUND

To investigate the efficiency of surgical operation for patients over 70 years with hypopharyngeal cancer.

MATERIALS AND METHODS

A retrospective analysis of the medical records from 68 patients over 70 years-old with hypopharyngeal cancer who underwent different therapeutic regimen between 2000 and 2009 was conducted. 36 of 68 patients underwent larynx preservation. All patients were treated with surgical operation and adjuvant radiotherapy. A Kaplan-Meier method was employed to calculate the survival rate.

RESULTS

Overall 3 year-and 5 year-survival rates were 48.6% and 29.4% respectively. For patients who underwent larynx preservation, 5 year-survival rate was 30.5%, which was decreased compared to 3 year-survival rate (46.9%) However, 3 year- and 5 year-survival rates in patients without larynx preservation were 46.9% and 28.1% respectively, suggesting that no statistically significant difference of survival rates was found between patients with or without larynx preservation (P > 0.05). A majority of patients who receive larynx preservation exhibited normal breathing and eating abilities and could present an intelligible speech. 16 of 36 patients who preserved larynx and 14 of 32 patients who underwent laryngectomy showed postoperative complication. No significant difference was observed in these two treatments, indicating larynx preservation is not a factor for inducing complication.

CONCLUSION

This study provides evidence that the quality of life for elderly patients with hypopharyngeal cancer can be improved by optimizing the therapeutic regimen based on the physical condition of each patient.

Upper Mediastinal Node Dissection for Hypopharyngeal and Cervical Esophageal Carcinomas

Objectives:

Hypopharyngeal cancer (HPC) and cervical esophageal cancer (Ce) are aggressive tumors with a poor prognosis. Multiple lymph node metastases often occur in the upper mediastinum, as well as in the neck, and thus upper mediastinal dissection (MD) is crucial to improving the cure rate. However, excessive MD can increase postoperative morbidity and mortality, making it important to employ the proper technique and appropriate extent of dissection. In the present retrospective study we aimed to determine the proper extent of upper MD according to tumor site and stage. The benefit and risk of upper MD are also discussed.

Methods:

Chart review was completed for patients who underwent upper MD, including 64 patients with HPC, 21 patients with Ce, and 9 patients with Ce extending to involve the upper thoracic esophagus (Ce/Ut). The incidence and distribution of lymph node metastases in the upper mediastinum were assessed by postoperative histopathologic examination. Postoperative complications of upper MD, as well as the impact on survival and locoregional control, were also reviewed.

Results:

Upper mediastinal metastases were detected in 7.8% of HPC patients, 33.3% of Ce patients, and 55.6% of Ce/Ut patients. In HPC patients, mediastinal metastases were usually associated with T4 primary tumors (80%), whereas positive nodes in the upper mediastinum were detected regardless of T stage in both Ce and Ce/Ut. Only 1 Ce/Ut patient with a T4 tumor developed late nodal metastasis in the lower mediastinum. The 5-year disease-specific survival and locoregional control rates were 58.6% and 90.2% in HPC, 45.5% and 94.1% in Ce, and 38.9% and 77.7% in Ce/Ut, respectively. Rupture of the greater vessels after MD was observed in 5 cases (5.3%).

Conclusions:

The present results indicate excellent locoregional control rates following upper MD, while major complications such as arterial breakdown were rare. It is suggested that upper MD may be an essential and adequate procedure for patients with Ce or Ce/Ut tumors, and may also be required for cases of HPC with a T4 primary to improve locoregional control of the disease.

Different clinical outcomes between locally advanced hypopharyngeal and oropharyngeal cancer treated with definitive concurrent chemoradiotherapy: implication for subgroup selection for induction chemotherapy

OBJECTIVE

The purpose of this study is to compare the long-term clinical outcome of hypopharynx cancer and oropharynx cancer treated with concurrent chemoradiotherapy.

METHODS

A total of 213 patients with locally advanced hypopharyngeal squamous cell carcinoma (n = 79) or oropharygeal squamous cell carcinoma (n = 134) were included. All patients were treated with upfront concurrent chemoradiotherapy between 1995 and 2012.

RESULTS

The median overall survival and progression-free survival differed significantly between the two groups (P < 0.05). Overall survival and progression-free survival rates at 3 years were 52% and 42% for hypopharynx cancer, and 75% and 72% for oropharynx cancer, respectively. There was no significant difference in the overall incidence of distant metastases but more locoregional recurrences occurred in patients with hypopharynx cancer compared with those with oropharynx cancer with a statistical significance (P < 0.001).

CONCLUSIONS

Patients diagnosed with locally advanced hypopharyngeal had relatively poor survival after upfront concurrent chemoradiotherapy. More intensive treatment such as induction chemotherapy before concurrent chemoradiotherapy might be needed to improve survival outcome in this subgroup of patients.

Pattern of cervical lymph node metastasis in medial wall pyriform sinus carcinoma

OBJECTIVES/HYPOTHESIS

The aim of this study was to analyze the prevalence and distribution of histologic cervical lymph node metastases in medial wall pyriform sinus squamous cell carcinoma (SCC).

STUDY DESIGN

Retrospective study of medical records.

METHODS

We reviewed the medical records of 68 medial wall pyriform sinus SCC patients who underwent bilateral neck dissection for primary treatment with curative intent. Thirty-nine patients underwent central compartment neck dissection. Primary tumor was removed using conservative laryngeal surgery with partial pharyngectomy in 39 cases, near total/total laryngectomy with partial pharyngectomy in 24 cases, and total laryngopharyngectomy in five cases.

RESULTS

The overall N(+) contralateral lymph nodes rate on pathology was 14.7%. The rate of contralateral occult cases was 5.2%. Advanced primary (T3-4) and nodal (N2b-3) disease, and primary lesion across the midline were correlated with contralateral nodal metastasis. Multivariate analysis revealed that a primary lesion across the midline was an independent factor for contralateral neck nodal metastasis. The rate of level VI node metastasis was 16.2%. The disease-specific survival rate was significantly different according to level VI node metastasis (71% vs. 40%). Pyriform sinus apex invasion and extralaryngeal spread were correlated with level VI nodal metastasis. Multivariate analysis revealed that pyriform sinus apex invasion was an independent factor for level VI nodal metastasis.

CONCLUSIONS

Contralateral nodal metastasis was less frequent than expected. Bilateral neck dissection is mandatory for primary lesion across the midline. Ipsilateral level VI lymph node should be removed in pyriform sinus apex invasion cases.

LEVEL OF EVIDENCE

4.

Characteristics and prognostic implications of high-risk HPV-associated hypopharyngeal cancers

Background

High-risk human papillomavirus (HPV) is an oncogenic virus that causes oropharyngeal cancers, and it has a favorable outcome after the treatment. Unlike in oropharyngeal cancer, the prevalence and role of high-risk HPV in the etiology of hypopharyngeal squamous cell carcinoma (HPSCC) is uncertain.

Objective

The aim of the present study was to evaluate the effect and prognostic significance of high-risk HPV in patients with HPSCC.

Methods

The study included 64 subjects with HPSCC who underwent radical surgery with or without radiation-based adjuvant therapy. Primary tumor sites were the pyriform sinus in 42 patients, posterior pharyngeal wall in 19 patients, and postcricoid area in 3 patients. High-risk HPV in situ hybridization was performed to detect HPV infection.

Results

The positive rate of high-risk HPV in situ hybridization was 10.9% (7/64). There was a significant difference in the fraction of positive high-risk HPV among pyriform sinus cancer (16.7%), posterior pharyngeal wall cancer (0%), and postcricoid area cancer (0%) (p = 0.042). The laryngoscopic examination revealed a granulomatous and exophytic appearance in 85.7% (6/7) of patients with high-risk HPV-positive pyriform sinus cancer, but in only 31.4% (11/35) of patients with high-risk HPV-negative pyriform sinus cancer (p = 0.012). Significant correlations were found between positive high-risk HPV and younger age (p = 0.050) and non-smoking status (p = 0.017). HPV-positive patients had a significantly better disease-free survival (p = 0.026) and disease-specific survival (p = 0.047) than HPV-negative patients.

Conclusions

High-risk HPV infection is significantly related to pyriform sinus cancer in patients with HPSCC.

Epidemiological assessment and therapeutic response in hypopharyngeal cancer

Despite the low incidence, diagnostic and therapeutic advances, hypopharyngeal cancer still has high mortality.

Objective

To evaluate retrospectively the epidemiological profile and response to surgery and radiation/chemotherapy of patients with hypopharyngeal cancer.

Method

We reviewed the medical records of 114 patients treated between 2002 and 2009 in a tertiary hospital with histopathological diagnosis of squamous cell carcinoma.

Results

The mean age of the patients was 57 years, 94.7% were males and 5.3% females, 98.2% were smokers and 92% consumed alcohol; 72% are illiterate or did not complete first grade schooling. The main complaints were: neck node (28%), pain and dysphagia (22%), odynophagia (12.2%), dysphonia (7.8%). The clinical staging was: I (1.7%), II (3.5%), III (18.4%), IV (76.3%). The treatment was carried out with radiotherapy and chemotherapy alone in 35%, with mean 2-year survival of 20% and 5-year survival of 18%; surgery followed by radiotherapy and chemotherapy in 22.8% with 2-year survival of 60.0% and 5 years of 55.0%; chemotherapy alone in 2.6%, and 39.4% without treatment.

Conclusion

Most patients already had advanced clinical stages and independent of the treatment option, had a low survival rate, confirming the poor prognosis of this neoplasm.

Current management strategy of hypopharyngeal carcinoma

OBJECTIVES

Squamous cell carcinoma (SCC) of the hypopharynx represents a distinct clinical entity among other cancers of the head and neck region. Despite recent advances in chemoradiotherapy, surgery remains the preferred therapeutic option for locally advanced disease and salvage for failure after chemo-radiotherapy. In this article, several aspects of surgical and non-surgical approaches in the management of hypopharyngeal cancer are discussed.

METHODS

A search in pubmed was made for publications with regard to the management of hypopharyngeal carcinoma.

RESULTS

In early-staged hypopharyngeal cancer, the overall and disease-specific survival rates after organ-preserving radiotherapy is comparable to that after surgery. However, for advanced staged disease, the results initial surgery with post-operative adjuvant radiotherapy was superior to chemoradiotherapy alone. The incidence of occult nodal metastasis is found to be more than 20%. Selective neck dissection removing cervical lymph node level II-IV is the procedure of choice for patients with clinically N0 neck. Contralateral nodal clearance may also be considered in tumors involving the medial wall of the pyriform recess, post-crioid region or the posterior wall, and those with ipsilateral palpable nodal metastasis and clinical stage IV disease. Transoral robotic surgery (TORS) has the potential value as the minimally invasive procedure for the management of carcinoma of the hypopharynx.

CONCLUSIONS

The treatment strategy for carcinoma of the hypopharynx has been evolving with time. Organ preserving chemoradiotherapy has been the treatment of choice for early stage disease, with surgical resection and reconstruction reserved for advanced and recurrent tumors.

Organ preservation surgery for advanced hypopharyngeal cancer

CONCLUSION

Organ preservation surgery with partial pharyngectomy preserving the larynx is feasible for the treatment of advanced hypopharyngeal cancer with comparable local control and preservation of function.

OBJECTIVES

To examine the feasibility and therapeutic effects of organ preservation surgery for advanced hypopharyngeal cancer.

METHODS

Fourteen patients with stage III/IV hypopharyngeal cancer were treated by partial pharyngectomy with or without partial laryngectomy to preserve the larynx. Ten cases were T1/2 primary while four cases had T3/4 tumors. Reconstruction of the pharyngolarynx was completed by primary mucosal suture in six, while free forearm flap was used in eight cases. Induction chemotherapy was administered for six cases including three with T3/4 tumors.

RESULTS

Five-year overall survival and disease-specific survival rates were 57.1% and 66.7%, respectively. The 5-year locoregional control rate was 66.7% and the larynx preservation rate was 100%. No patients presented with local recurrence at the pharyngolaryngeal segment, while two cases showed nodal recurrence, from which they died. Tracheal stoma was closed in 9 of 14 cases. Vocal function was excellent in five cases, moderate in five, and poor in three. Swallowing function was excellent to moderate in eight cases and poor in six.

Management of stage I/II hypopharyngeal cancer

CONCLUSIONS

It is suggested that radiotherapy might be the first choice for stage I/II hypopharyngeal cancer, and that adjuvant treatment might be necessary for stage II patients to prevent distant metastasis.

OBJECTIVES

To update the therapeutic outcome of early hypopharyngeal cancer.

METHODS

Twenty-eight patients with stage I/II hypopharyngeal cancer (8 in stage I, 20 in stage II) were treated at Kyoto University Hospital between 1995 and 2007. Of 8 cases in stage I, radiotherapy was applied for 4 cases, and surgical treatment for another 4, while 13 of 20 cases in stage II underwent radiotherapy and the remaining 7 cases underwent surgery.

RESULTS

The 5-year cumulative disease-specific survival and larynx preservation rates were 74.6% and 73.2%, respectively. Recurrent tumors were found in two cases in stage I treated by surgery and in five cases in stage II treated with radiotherapy. Two of five recurrent cases in stage II were rescued by salvage surgery. Distant metastasis to the lung appeared in two cases in stage II after initial treatment.

Ten years single institutional experience of treatment for advanced hypopharyngeal cancer in Kyoto University

CONCLUSION

Treatment of advanced hypopharyngeal cancer has become more conservative and more multidisciplinary, and the prognosis has been improved. Induction chemotherapy has the potential to extend organ preservation therapy even in cases with locally advanced primary lesion. It is also important to develop a strategy to reduce distant metastasis and to keep track of second primary cancers.

OBJECTIVES

To update the therapeutic outcome of advanced hypopharyngeal cancer.

METHODS

A total of 72 cases with stage III/IV hypopharyngeal cancer were treated at Kyoto University Hospital during 2000-2008. Surgery was performed in 56 cases; total pharyngolaryngoesophagectomy (TPLE) in 39 cases and partial pharyngectomy (PPX) preserving the larynx in 17 cases. Radiotherapy (RT) with or without concurrent chemotherapy was applied in 16 cases. Induction chemotherapy (ICT) has been applied for 14 cases since 2006 to achieve organ preservation and reduction of distant metastasis. The follow-up period varied from 12 months to 96 months (mean 32 months). Therapeutic outcomes were chart reviewed.

RESULTS

Five years cumulative overall and disease-specific survival (DSS) rates were 52.1% and 63.8%, respectively. DSS rates in cases treated with surgery and those with RT were 65.1% and 56.1%, respectively. N2c status showed the worst prognosis according to nodal disease classification. Local control rates for cases treated with TPLE, PPX, and RT were 97.3%, 100%, and 80.4%, respectively. The effective rate of ICT was 79%, and laryngeal preservation was achieved in 79% of the cases with ICT. Recurrence occurred in 20 cases. Approximately half of the recurrence was distant disease. In the end, 17 cases died of the primary disease, while 10 cases died of other causes, mainly second primary cancers.

Neck restaging with sentinel node biopsy in T1-T2N0 oral and oropharyngeal cancer: Why and how?

Objective: To evaluate the lack of accuracy in neck staging with the classical technique (i.e., neck dissection and routine histopathology) with the sentinel node (SN) biopsy in oral and oropharyngeal T1-T2N0 cancer.

Study Design: Cross-sectional study with planned data collection.

Setting: Tertiary center care.

Subjects and Methods: In 50 consecutive patients, the pathological stage of sentinel node (pSN) was established after analyzing SN biopsies (n = 148) using serial sectioning and immunohistochemistry. Systematic selective neck dissection was performed. The pN stage was established with routine histopathologic analysis of both the non-SN (n = 1075) and the 148 SN biopsies.

Results: The sensitivity and negative predictive value of pSN staging were 100 percent. Conversely, if one considers pSN staging procedure as the reference test for micro- and macro-metastasis diagnosis, the sensitivity of the classical pN staging procedure was 50 percent (9/1; 95% CI 26.9-73.1) and its negative predictive value was 78 percent (95% CI 61.9-88.8). Fifteen patients (30%) were upstaged, including nine cases from pN0 to pSN ≥ 1 and six cases from pN1 to pSN2. Two of the pN0-pSN1 upstaged patients died with relapsed neck disease.

Conclusion: The SN biopsy technique appeared to be the best staging method in cN0 patients and provided evidence that routinely undiagnosed lymph node invasion may have clinical significance.

Indication of elective contralateral neck dissection in squamous cell carcinoma of the hypopharynx

Lymph node metastases (LNM) are common in hypophariyngeal carcinomas; the neck dissection is an important therapeutic approach.

Aim

to analyze the incidence and distribution of LNM and failures in treating the contralateral neck.

Methods

a retrospective study of 174 patients with hypopharyngeal cancer treated from 1978 to 2003. The distribution of LNM and regional recurrences were evaluated.

Results

44% of the cases were false negatives and 4.9% were false positives. Among the 48 patients who underwent bilateral ND, 29 had bilateral metastases and one had contralateral metastasis. Contralateral neck recurrences occurred in 12 cases that underwent unilateral ND. Among the nine patients with contralateral neck recurrence alone, eight were surgically salvaged. The risk of contralateral metastases was related to clinical staging (p=0.003) and involvement of the medial wall of the pyriform sinus (p=0.03), but not to radiotherapy (p=0.28).

Conclusion

Contralateral metastases were more frequent when the medial wall of the pyriform sinus was affected, in the presence of ipsilateral palpable metastases and clinical stage IV.

Results after radical surgical treatment for advanced carcinoma of hypopharynx

The aim of the study was to investigate patients with hypopharyngeal cancer. And this study focuses on a case series with hypopharynx cancer and cervical oesophageal cancer invading the hypopharynx. There were 13 cases over a period of 8 years, treated with pharyngo-laryngo-esophagectomy (PLE) and cervical lymph node dissection. In 10 of the patients, reconstruction was done with gastric pull-up (GP). In 3 of the 10 patients gastric reconstruction was added to aid in pyloric drainage (2 pyloromyotomy and 1 pyloroplasty) but the remaining 7 patients did not receive such procedures. The reconstruction of the digestive system after PLE is still a matter of debate. GP method is the most frequently preferred method for reconstruction. We believe that a more important problem than gastric drainage is the reflux of the gastric content and pyloric drainage which will not have a positive effect for solving this clinical situation. But we need bigger series for analyze of this specific condition.

Voice and swallowing after laryngopharyngectomy and free ileocolic flap reconstruction for hypopharyngeal cancer

Sixteen patients with hypopharyngeal carcinoma who underwent laryngopharyngectomy had immediate reconstruction with a free ileocolic flap to restore voice and swallowing. All patients had satisfactory voice production and swallowing in the early postoperative stage. Maintaining adequate tension and decreasing redundancy of the transferred colon prevented food pooling and provided smooth, rapid swallowing. A wedge resection of the subserosa of the ileocecal valve to increase the intraluminal pressure helped prevent food reflux and provide good phonation. Although this modified technique yielded good initial results, both voice and swallowing deteriorated after concurrent chemoradiotherapy, possibly because of radiation injury to the transferred bowel.

Therapeutic selective neck dissection (level II-V) for node-positive hypopharyngeal carcinoma: is it oncologically safe?

CONCLUSIONS

Our study suggests that routine level I dissection may not be necessary in the surgical management of clinically N + hypopharyngeal squamous cell carcinoma (SCC) in patients who do not have a positive lymph node in neck level I.

OBJECTIVE

To determine whether level I lymph node dissection can be saved in patients with clinically N + hypopharyngeal SCC.

PATIENTS AND METHODS

Retrospective analysis of 64 consecutive clinically N + patients with untreated hypopharyngeal SCC between 1994 and 2006. Forty-seven patients underwent level I lymph node dissection and the remaining 17 did not. Forty-five of the 64 patients were followed for a minimum of 2 years, if alive, or until death. Of these 45 patients, 35 underwent ipsilateral level I dissection of the neck.

RESULTS

The incidence of occult metastases to level I was 6% (3 of 47). Six (17%) of 35 patients with level I dissection and 1 (10%) of 10 patients without level I dissection experienced regional recurrence (p>0.05). The 2-year disease-specific survival in 47 patients undergoing level I neck dissection was 44% compared with 37% in 17 patients who did not undergo level I neck dissection (p>0.05).

Elective and therapeutic selective neck dissection

Selective neck dissection is a modification of the more comprehensive modified radical or radical neck dissection that is designed to remove only those nodal levels considered to be at risk for harboring nodal metastases. The role of selective neck dissection continues to evolve: while initially designed as a staging and diagnostic procedure for patients without clinical evidence of nodal disease, a growing body of literature suggests that selective neck dissection has a therapeutic role in patients with clinical and histologic evidence of nodal metastases. The rationale behind selective neck dissection, its application in the clinically negative but histologically node-positive neck and the extended application of selective neck dissection in patients with clinical evidence of nodal disease are discussed.